What is the first-line therapy for osteoporosis in a male patient with bilateral hip involvement?

From the Guidelines

The first-line therapy for osteoporosis in a male patient with involvement of both hips is typically bisphosphonate medication, specifically alendronate (Fosamax) 70 mg orally once weekly or risedronate (Actonel) 35 mg orally once weekly. These medications should be taken on an empty stomach with a full glass of water, and the patient should remain upright for at least 30 minutes afterward to prevent esophageal irritation. Treatment duration is generally 3-5 years initially, with periodic reassessment of fracture risk. In addition to medication, the regimen should include calcium supplementation (1000-1200 mg daily) and vitamin D (800-1000 IU daily) 1. Weight-bearing exercises and resistance training are also important components of therapy. Bisphosphonates work by inhibiting osteoclast activity, thereby reducing bone resorption and increasing bone mineral density. This helps to strengthen the compromised hip bones and reduce fracture risk. Regular monitoring with bone mineral density testing every 1-2 years is recommended to assess treatment efficacy.

Some key points to consider when treating osteoporosis in men include:

• Ensuring adequate calcium and vitamin D intake 1
• Encouraging weight-bearing exercises and resistance training
• Monitoring bone mineral density regularly to assess treatment efficacy
• Considering the use of denosumab or zoledronate as second-line treatments for men at high risk of fracture 1
• Assessing serum total testosterone levels as part of the pre-treatment assessment 1

It's also important to note that the evidence base strongly supports the use of bisphosphonates or denosumab in the treatment of osteoporosis in men, and suggests that oral bisphosphonates should be recommended as first-line therapy with intravenous bisphosphonates as second-line therapy 1. Additionally, a 2023 systematic review and meta-analysis found that alendronate and risedronate improved bone mineral density at the lumbar spine, total hip, and femoral neck in men with osteoporosis 1.

Overall, the treatment of osteoporosis in men should be individualized and based on a thorough assessment of fracture risk and bone mineral density. Bisphosphonate medication, specifically alendronate or risedronate, is the recommended first-line therapy 1.

From the FDA Drug Label

Osteoporosis in Men Treatment of men with osteoporosis with alendronate sodium 10 mg/day for two years reduced urinary excretion of cross-linked N-telopeptides of type I collagen by approximately 60% and bone-specific alkaline phosphatase by approximately 40%. Similar reductions were observed in a one-year study in men with osteoporosis receiving once weekly alendronate sodium 70 mg

The first line therapy for osteoporosis in a male patient is alendronate sodium 10 mg/day or once weekly alendronate sodium 70 mg.

• Key benefits:
  • Reduction in urinary excretion of cross-linked N-telopeptides of type I collagen by approximately 60%
  • Reduction in bone-specific alkaline phosphatase by approximately 40% 2

From the Research

First Line Therapy for Osteoporosis in Male Patients

• The first line therapy for osteoporosis in male patients, including those with osteoporosis in both hips, is bisphosphonates 3.
• Bisphosphonates are recommended for men with osteoporosis and for high-risk men with low bone mass (osteopenia) with a T-score of -1 to -2.5 3.
• A systematic review with network meta-analyses found that zoledronic acid seemed the most effective in preventing vertebral fracture, nonvertebral fracture, and any fracture, and alendronate or zoledronic acid seemed the most effective in preventing hip fracture 4.
• Other studies have also shown that bisphosphonates, including alendronate, risedronate, ibandronate, and zoledronic acid, reduce the relative risk of new vertebral fractures in patients with osteoporosis, and some also reduce the relative risk of new nonvertebral and hip fractures 5.

Benefits and Risks of Bisphosphonates

• Bisphosphonates reduce the risk of fracture by suppressing bone resorption and increasing bone strength 6.
• The use of bisphosphonates for the management of osteoporosis remains a clinical challenge, with important considerations including appropriate patient selection, pretreatment evaluation, potential adverse effects, patient preferences, and adherence 6.
• Patients at high risk of fracture should consider treatment with antiresorptive therapy, including bisphosphonates and denosumab, while anabolic agents such as teriparatide, abaloparatide, and romosozumab should be considered for patients at very high risk or with previous vertebral fractures 7.